Provider Demographics
NPI:1730077926
Name:WIBLE, LA'TISA M (RN, BSN)
Entity type:Individual
Prefix:
First Name:LA'TISA
Middle Name:M
Last Name:WIBLE
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 SUMMERTIME AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7524
Mailing Address - Country:US
Mailing Address - Phone:616-240-5798
Mailing Address - Fax:
Practice Address - Street 1:860 SUMMERTIME AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7524
Practice Address - Country:US
Practice Address - Phone:616-240-5798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-25
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula